Clinical SHOWCASE
Diagnosing Denture Pain: Principles and Practice
Robert W. Loney, DMD, MS
C
linicians can use 5 strategies to save
time and minimize repeat visits for
patients who have problems with
their complete or removable partial
dentures: 1) establish the differential
diagnosis, 2) identify variations from
normal, 3) have the patient demonstrate
the problem, 4) always use an indicating
medium when making adjustments to
prostheses and 5) have the patient rate
perceived improvement after adjustments.
Dr. Loney’s full-day
session at the CDA Annual
Establish the Differential Diagnosis
Convention, titled To eliminate a denture problem, its
“Making removable
cause must first be correctly identified.
prostheses work,” will be
Take a good history and perform a thor-
presented on Saturday,
ough clinical examination. Establish a list
August 26. For more
of potential causes (the differential diag-
information on the 2006
nosis), rank them according to frequency,
CDA Annual Convention,
and begin by eliminating those most likely
to be held August 24–26 in
to be causing the problem in the partic-
St. John’s, Newfoundland,
visit the CDA website at
ular patient. If the cause of the problem is
correctly identified and addressed, the
www.cda-adc.ca.
pain, ulceration and other related signs
and symptoms should resolve in 10 to 14
days.1 Biopsy is mandatory for any lesion
that fails to heal within 14 days after
onset,2 particularly when a denture has
Figure 1: The posterior buccal flange of
this denture is shorter than normal and
should be extended to the dotted line.
Compound or light-cured acrylic resin
could be added to the periphery in an
attempt to extend the border. When this
approach was taken in this case, the
patient’s denture became markedly more
retentive.
JCDA • www.cda-adc.ca/jcda • March 2006, Vol. 72, No. 2 •
been ruled out as the source of the ulcer.
Work down the list of possible diagnoses
until the problem is solved.2
Diagnosing the problem requires a thor-
ough history from the patient, including the
following specific information:
• When did the pain start?
• How long does it last?
• What makes it better?
• What makes it worse?
Combined with information from the
clinical examination, this information will
help to establish the differential diagnosis,
and the clinician can rank the most likely
causes at the top of the list. The clinical
examination should incorporate the
strategies of identifying variations from
normal, having denture patients demon-
strate their problems and using an indi-
cating medium.
Identify Variations from Normal
Many denture problems can be identi-
fied by inspecting the dentures critically
for variations from normal (Figs. 1 to 7).
Unusual extensions, contours, tooth posi-
tions, thickness and finish can all be
sources of denture problems. Intraoral
Figure 2: The transparent areas of resin over
the tuberosities provide a clue that the lower
denture is contacting the upper denture,
thereby causing wear to the base. Such
contact can cause the denture to loosen.
137

Figure 3: Severe and uneven wear on these
dentures is responsible for esthetic problems,
discomfort and difficulty chewing.
Figure 6: Posterior interferences between the
denture bases can cause tipping of the den-
tures, which results in pain similar to that
caused by occlusal problems.
Figure 9: This patient has very tight pterygo-
mandibular raphes (arrows). As the raphes
tighten during opening, they pull on the
posterior border of the denture, causing it to
loosen (the patient’s chief concern). Relief for
these structures should be provided during
the making of the impressions. This case
emphasizes that anatomic variations must be
identified to minimize denture problems.
138
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Figure 4: The distolingual flange of this
mandibular denture looks different from a
typical flange. Normally, the flange contour
will either proceed straight down or arc gently
downward and forward from the pear-shaped
pad, but this one extends too far posteriorly
from the position of the retromolar pad. This
overextension caused pain on swallowing.
Figure 7: It is usually better to place and load
posterior denture teeth centrally (C) over the
ridge.3 More tipping problems result when
occlusal forces are applied buccal to the ridge
(B).4 These tipping problems can cause both
looseness and pain.
Figure 10: In this patient, the deep midline
soft-tissue fissure at the posterior of the
palate caused a break in the seal of the
denture, which in turn caused looseness and
dropping of the denture. Special attention is
needed to ensure that the posterior palatal
seal of the denture maintains tissue contact to
provide adequate retention.
JCDA • www.cda-adc.ca/jcda • March 2006, Vol. 72, No. 2 •
Figure 5: This patient had multiple sore
spots associated with the denture, and
previous adjustments to the denture
bases had not provided any relief. The
denture midlines are off, and the
denture teeth in the second and third
quadrants are meeting cusp to cusp,
which suggests that poor occlusion
could be the cause of the patient’s
problems.
Figure 8: This patient had 3 unsuc-
cessful maxillary partial dentures made
within 1 year. Each time, she had
requested only a new “upper plate and
nothing else.” However, all 3 dentures
had failed because of facture of the den-
ture teeth and severe mobility of the
prosthesis. The real problem was a lack
of interarch space for the prosthesis,
which the care providers had failed to
identify because, in taking direction from
the patient, they were looking only at
the maxillary arch. The lesson from this
case is that the clinical examination must
be thorough, to ensure that all potential
problems and variations from normal are
identified.
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Figure 11: Ulcers, sore spots or areas of
hyperkeratosis on the sides of the
ridges, which are not identified by
pressure indication medium, are typically
caused by tipping of the denture.
Tipping is frequently associated with
occlusal problems.
Figure 12: Posterior teeth set over the
ascending portion of the ramus can cause a
denture to slide or shift during function,5
causing occlusion-related pain. Therefore,
do not set denture teeth posterior to the
position indicated by the arrow.
Figure 13: When a single denture opposes
the natural dentition, the occlusal plane
should not have a severe curve of Spee. Such
a curve will place tilting forces on the denture
in excursive movements, which frequently
causes both looseness and discomfort.

Figure 14: Areas of inflammation or
ulceration that are caused by the den-
ture base are often discrete and cannot
be distinguished from similar areas
related to occlusal problems. The diag-
nosis must be established through the
history, a clinical examination and indi-
cating medium. The definitive diagnosis
is often determined by exclusion of
other possible causes.
Figure 15: This patient is using a small piece
of cotton roll to demonstrate where the
maxillary denture loosens when he is
chewing. Having patients demonstrate their
problems while the dentist watches can often
expedite the diagnosis of denture problems.

inspection for anatomic or tissue abnormalities or
variants may also give clues to the cause of some
denture problems (Figs. 8 to 14). If an abnormality
is found and corrected, the signs and symptoms
should resolve within 10 to 14 days.
Have the Patient Demonstrate the Problem
Asking the patient to demonstrate how the
problem occurs often helps the clinician to identify
its source. If the problem occurs only when the
patient chews, cut a small piece of a cotton roll,
dampen it, and let the patient demonstrate the loca-
tion where the bolus causes the symptom (Fig. 15).
If the problem occurs during speaking, singing,
drinking or opening wide, have the patient replicate
the circumstances. Have the patient describe what
they experience, and watch carefully to determine
the cause of the problem. Attempt to eliminate the
cause and recall the patient in 10–14 days to ensure
that the signs and symptoms have resolved.
Use an Indicating Medium when Making
Adjustments
Clinicians usually check occlusion of restora-
tions using an indicator such as articulating paper
or shim stock. Similarly, denture adjustments are
more accurate and effective when an indicating
medium is used. Pressure- or fit-checking medium,
indelible markers and articulating paper can all be
used to aid in locating a problem and determining
the degree of adjustment that is required (Figs. 16
to 20).

JCDA • www.cda-adc.ca/jcda • March 2006, Vol. 72, No. 2 • 139

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Figure 16: Pressure-indicating medium is nec- Figure 17: A well-adjusted denture base. Figure 18: Lines of burn-through on
essary to identify denture base impingements. Areas of tissue inflammation that do not flanges often indicate areas that are
Apply the medium with a stiff bristle brush, correlate to areas of burn-through are most overextended or too thick. They may
coating the denture with enough paste so likely caused by tilting of the denture. require repeated adjustments and
that the base is mostly the colour of the Potential occlusal causes should be investi- applications of paste.
medium. Leave streaks in the paste. Place the gated.
denture intraorally, avoiding contact with
cheeks and lips. Press firmly into place over
the first molars. Do not tip, tilt or wiggle.
Remove and inspect the denture. Areas with
paste and no brush strokes represent areas of
moderate tissue contact (C). Areas without
paste (burn-through) represent areas of tissue
impingement (I). Areas with streaks remaining
in the paste have not contacted the tissue (N).

Box 1 Typical histories for patients with denture pain

For pain related to occlusion

Hurts only when chewing
Gets worse with chewing
Gets worse as the day progresses
Patient may have to remove prosthesis late in the day because
of discomfort
For pain related to denture base fit
Problem starts when the patient inserts the denture, which often
feels tight or causes soreness
Patient has discomfort even when not chewing
May or may not get worse as the day progresses
For pain related to occlusal vertical dimension (OVD)5,6
Insufficient OVD (Fig. 21)
Lack of chewing power
Minimal ridge discomfort
Angular cheilitis
Chin prominent
Minimal display of vermilion border
Excessive OVD (Fig. 21)
Soreness over entire ridge
Worse during the day (increased occlusal contact)
Dentures “click” when speaking
Mouth feels “too full,” patient has difficulty getting lips together

140 JCDA • www.cda-adc.ca/jcda • March 2006, Vol. 72, No. 2 •

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Figure 19: Pressure-indicating medium
can be used on non-bearing surfaces of
the denture to identify other undesirable
contours. This photo demonstrates an
impingement of the coronoid process
on the posterior denture flange during
lateral excursion. This interference
caused both pain and loosening of the
denture.
Figure 20: A sharp, thin or overextended
periphery in the hamular notch area can cause
painful ulcers. Use of indicating medium is
critical for adjustment of these areas, because
removal of acrylic in the wrong area can result
in a breach of the posterior palatal seal, which
will result in loosening of the denture and little
relief of the discomfort.
Figure 21: Examples of insufficient (left) and
excessive (right) occlusal dimension. Although
adjustments are sometimes helpful, a remake
of the denture is usually required to
completely resolve these serious denture
problems.

Have the Patient Rate Perceived
Improvement after Adjustments
If a clinician asks the patient whether a denture
adjustment has made the situation better, the most
likely response is “yes.” But if the adjustment has
improved the situation by only 20%, the patient
is likely to return with the same problem at a
subsequent appointment. A better question is
“How does that feel?” If the patient states that it
feels “better,” he or she should be asked to rate
how much better, in terms of a percentage. An
ulceration may not feel 100% better at the end of
an appointment, but the improvement should feel
closer to 90% than to 20%.
Causes of Denture Pain
Possible causes of denture pain include occlu-
sion, denture base (fit and contour), vertical
dimension, infection, a systemic disease or condi-
tion, or an allergy (rare).
It is probable, although unproven, that occlu-
sion and poor fit of the denture base cause more
repeat visits for denture-related pain than the other
causes listed. The latter 3 causes (infection, disease
and allergy) should never be overlooked, especially
when ulcers or pain are persistent despite interven-
tions, but for the purposes of this paper, only the
first 3 causes are addressed (Box 1).
Conclusion
Many clinicians deal with denture-related pain
by grinding the denture base in the area of the
reported pain. This type of blanket solution is
akin to a physician prescribing a broad-spectrum
antibiotic to all patients who have a sore throat
and runny nose. It assumes, incorrectly, that the
denture base is the source of all denture pain.
Clinicians can save time and minimize repeat visits
for patients with denture problems when they use a
systematic approach to correctly diagnose denture
pain. C
THE AUTHOR
Dr. Loney is a professor and director of the graduate
prosthodontics program in the department of
dental clinical sciences, faculty of dentistry, Dalhousie
University, Halifax, Nova Scotia. Email: robert.loney
@dal.ca.
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4. Browning JD, Jameson WE, Stewart CD, McGarrah HE, Eick JD.
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